Pharmaceutical compositions and methods for anesthesiological applications

ABSTRACT

Pharmaceutical compositions and methods for inducing conscious sedation using such compositions are described, the compositions comprising a benzodiazepine-based compound, a NMDA antagonist, and optionally a β-blocker, antiemetic, an NSAID, and/or an antihistamine medication. Methods for fabricating the compositions and using them for anesthesiological applications are also described.

CROSS REFERENCE TO RELATED APPLICATIONS

This is a continuation-in-part application claiming the benefit of priority under 35 U.S.C. § 120 to U.S. application Ser. No. 15/903,529, filed Feb. 23, 2018, now pending, which is a continuation-in-part of Ser. No. 15/184,768, filed Jun. 16, 2016, now issued as U.S. Pat. No. 9,918,993, which claims the benefit of priority under 35 U.S.C. § 119(e) of U.S. Provisional App. No. 62/182,130, filed Jun. 19, 2015, the entire content of each of which is incorporated herein by reference. This application is also a continuation-in-part claiming the benefit of priority under 35 U.S.C. § 120 to U.S. application Ser. No. 15/903,615, filed Feb. 23, 2018, now pending, which is a continuation-in-part of Ser. No. 15/184,768, filed Jun. 16, 2016, now issued as U.S. Pat. No. 9,918,993, which claims the benefit of priority under 35 U.S.C. § 119(e) of U.S. Provisional App. No. 62/182,130, filed Jun. 19, 2015, the entire content of each of which is incorporated herein by reference.

FIELD OF THE INVENTION

The present invention relates generally to the field of pharmacology and more specifically to compositions having anesthetic properties that are useful in various kinds of surgery, e.g., ophthalmic surgery, and to methods of preparing and using such compositions.

BACKGROUND

The present disclosure relates to solid or liquid pharmaceutical formulations comprising combinations of active agents such as anesthetics, anti-emetics, anti-hypertensives, anti-anxiety medications and/or analgesics, and methods for using the same for providing anesthesia by administering such compositions rectal administration, nasal administration (including via a nasal spray), oral spray administration, transdermal administration, and transmucosal administration including that utilizing a transmucosal gel. The formulations may also include slow release reversal agents that would counteract the initial anesthesia effect.

It is necessary in many cases to use local anesthesia, particularly via such routes of adminisration in the course of various surgical procedures, e.g., ophthalmic surgeries or urological interventions. For instance, when local anesthesia is employed during or prior to intraocular operations, the occurrences of pain, anxiety, peri-operative stress, nausea, agitation, vomiting and the like are less frequent, which will typically have a very beneficial effect on the surgical experience and reducing the number of intraocular complications such as bleeding, secretions, cardiac and/or pulmonary complications, etc. The severity of those complications when they do occur will also be less pronounced when local anesthesia is used.

Traditionally, an intravenous route is used to administer such medications.

Alternatives to intravenous methods and therapies have been suggested and previously used for the treatment. In particular, oral administration of benzodiazepines, opioid analgesics, propofol, ketamine or etomidate utilizing the MAC procedure (monitored anesthesia care) has been suggested and tried, but no more than minimal to moderate improvement has been achieved by such methods. Therefore, there remains a need for better treatments of these disorders.

This patent specification discloses such pharmaceutical compositions suitable for anesthesiological applications that can achieve positive patient outcomes while being free of drawbacks and deficiencies of existing methods and formulations. Methods of fabricating and administering the same are also discussed.

SUMMARY

According to one embodiment of the invention, there are provided pharmaceutical compositions. The compositions include a therapeutically effective quantity of at least one first pharmaceutically active compound comprising benzodiazepine moiety or pharmaceutically acceptable salts, hydrates, solvates or N-oxides thereof, a therapeutically effective quantity of at least one second pharmaceutically active compound that is an NMDA antagonist or pharmaceutically acceptable salts, hydrates, solvates or N-oxides thereof, and at least one pharmaceutically acceptable excipient or carrier therefor.

According to another embodiment of the invention, the pharmaceutical compositions described above may further include a therapeutically effective quantity of at least one third pharmaceutically active compound that is a β-blocker, an NSAID, or an antiemetic medicament, or a combination thereof, or pharmaceutically acceptable salts, hydrates, solvates or N-oxides thereof.

According to further embodiments of the invention, in the pharmaceutical compositions described above, the first pharmaceutically active compound may be any of midazolam, diazepam, lorazepam, flunitrazepam, alprazolam, chlordiazepoxide, clonazepam or clorazepate, the second pharmaceutically active compound may be any of ketamine, dextrorphan, etomidate, methadone, memantine, amantadine or dextromethorphan and the third pharmaceutically active compound may be (if a β-blocker) any of metoprolol, propranolol, acebutolol, nadolol, atenolol, betaxolol, esmolol, bisoprolol fumarate, carvedilol, nebivolol, penbutolol, timolol, or sotalol or (if an antiemetic) ondansentron, dolasetron, granisetron, palonosetron, promethazine, imenhydrinate, or meclizine.

According to yet another embodiment of the invention, there are provided further pharmaceutical compositions such as any described above, wherein the compositions are formulated as an item suitable for rectal administration, nasal administration (including via a nasal spray), oral spray administration, transdermal administration, and transmucosal administration including that utilizing a trnasmucosal gel.

According to other embodiments, there are provided specific compounds for making the compositions described above, for example, midazolam, ketamine and ondansetron, as well as methods for using above-mentioned composition(s) for the purposes of local anesthesia in various applications, such as ophthalmic surgery.

According to further embodiments of the invention, the above-mentioned methods of using the composition(s) include administering to a patient in need thereof (i.e., those patients who require conscious sedation or pre-sedation) a pharmaceutical composition described herein as the first step of the medical or surgical procedure, the procedure being an ophthalmic surgery (e.g., a cataract, glaucoma, corneal, eyelid surgery, or retinal surgery), a dental procedure (e.g., a tooth extraction, an oral surgery, or a root canal surgery), an outpatient medical procedure (e.g., medical imaging procedure, biopsy, bone marrow harvesting, colonoscopy, or endoscopy), a urological procedure (e.g., vasectomy), a laparoscopic procedure, obstetric and gynecological procedures, a gastrointestinal procedure, an otolaryngological procedure, a cosmetic surgery procedure, a dermatological procedure, a podiatric procedure, an orthopedic procedure, an emergency medical treatment, a psychiatric treatment, or a veterinarian procedure.

DETAILED DESCRIPTION A. Terms and Definitions

Unless specific definitions are provided, the nomenclatures utilized in connection with, and the laboratory procedures and techniques of analytical chemistry, synthetic organic and inorganic chemistry described herein, are those known in the art. Standard chemical symbols are used interchangeably with the full names represented by such symbols. Thus, for example, the terms “hydrogen” and “H” are understood to have identical meaning. Standard techniques may be used for chemical syntheses, chemical analyses, formulating compositions and testing them. The foregoing techniques and procedures can be generally performed according to conventional methods well known in the art.

It is to be understood that both the foregoing general description and the following detailed description are exemplary and explanatory only and are not restrictive of the invention claimed. As used herein, the use of the singular includes the plural unless specifically stated otherwise. The section headings used herein are for organizational purposes only and are not to be construed as limiting the subject matter described.

As used herein, “or” means “and/or” unless stated otherwise. Furthermore, use of the term “including” as well as other forms, such as “includes,” and “included,” is not limiting.

“About” as used herein means that a number referred to as “about” comprises the recited number plus or minus 1-10% of that recited number. For example, “about” 100 degrees can mean 95-105 degrees or as few as 99-101 degrees depending on the context. Whenever it appears herein, a numerical range such as “1 to 20” refers to each integer in the given range; i.e., meaning only 1, only 2, only 3, etc., up to and including only 20.

The term “pharmaceutical composition” is defined as a chemical or biological compound or substance, or a mixture or combination of two or more such compounds or substances, intended for use in the medical diagnosis, cure, treatment, or prevention of disease or pathology.

The terms “anesthetic,” “anesthesia,” “anesthesiology” and the like refer herein to substances, compounds, processes or procedures that induce insensitivity to pain such as a temporary loss of sensation.

The term “conscious sedation” that for the purposes of this application may be used interchangeably with the terms “procedural sedation” and “analgesia” is used herein to refer to an induced state of sedation characterized by a minimally depressed consciousness such that the patient is able to continuously and independently maintain a patent airway, retain protective reflexes, and remain responsive to verbal cues and/or tactile or physical stimulation.

Conscious sedation is typically performed to decrease the level of anxiety in a patient and to elicit an improved degree of cooperation from the patient. Conscious sedation, therefore, refers to a condition that is medically different and distinct from deep sedation which is the next level of sedation defined as depression of consciousness when the patient's ability to independently maintain ventilatory function may be impaired and he or she cannot be easily aroused; however, the patient will still purposefully respond to repeated or painful stimulation.

Conscious sedation is also clearly distinguishable for the purposes of the present application from the lower level of sedation (i.e., minimal sedation when the patient is able to maintain a normal response to verbal stimuli) as well as the highest level of sedation (i.e., general anesthesia when there is no response from the patient even with painful stimulus).

The term “pre-sedation” is defined for the purposes of this application as conscious sedation that is induced some time before the procedures, e.g, between 5 minutes and 1 hour prior.

The terms “solvate” and “hydrate” are used herein to indicate that a compound or substance is physically or chemically associated with a solvent for “solvates” such as water (for “hydrates”).

The term “NMDA antagonist” is defined as a compound that inhibits (“antagonizes”) the action of the N-methyl-D-aspartate receptors and is inclusive of both competitive and non-competitive antagonists, glycine antagonists and uncompetitive channel blockers, as these terms are understood by those having ordinary skill in the art.

The term “β-blocker” refers to a compound of any kind that can prevent or reduce the stimulation of the adrenergic receptors responsible for increased cardiac action.

The term “antiemetic” is defined as a drug or medicament that treats, reduces, and/or prevents nausea and/or vomiting.

The term “non-steroid anti-inflammatory drug” or “NSAID” refers to a class of compounds that are free of any steroid moieties yet are capable of providing analgesic, antipyretic and/or anti-inflammatory effects.

The term “antihistamine medicament” refers to any compound that is capable of inhibiting or counteracting the physiological effects of histamine.

The term “polyglycol” is defined as a polymer or oligomer containing several ether-glycol linkages that yields one or more glycols when these linkages are cleaved, e.g., by hydrolysis.

The term “carrier” refers to a substance that serves as a vehicle for improving the efficiency of delivery and the effectiveness of a pharmaceutical composition.

The term “excipient” refers to a pharmacologically inactive substance that is formulated in combination with the pharmacologically active ingredient of pharmaceutical composition and is inclusive of bulking agents, fillers, diluents and products used for facilitating drug absorption or solubility or for other pharmacokinetic considerations.

The term “therapeutically effective amount” is defined as the amount of a compound or pharmaceutical composition that will elicit the biological or medical response of a tissue, system, animal or human that is being sought by the researcher, medical doctor or other clinician.

The term “pharmaceutically acceptable” when used in reference to a carrier, whether a diluent or excipient, refers to a substance that is compatible with the other ingredients of the formulation and not deleterious to the recipient thereof.

The terms “administration of a composition” or “administering a composition” is defined to include an act of providing a compound of the invention or pharmaceutical composition to the subject in need of treatment.

The term “rectal administration” is broadly defined as a route of administration where a medication is inserted directly to the rectum of a patient for absorption by the rectum's blood vessels and flow into the body's circulatory system.

The term “nasal administration” (e.g., via a spray) is broadly defined as a route of administration in which a medication is insufflated directly through the patient's nasal cavity; e.g., a liquid medicine that is atomized into a fine spray and inhaled through the nose.

The term “oral spray administration” is defined as a route of administration whereby a medication is delivered via a spray through the patient's mouth (e.g., a liquid medicine that is atomized into a fine spray and inhaled through the mouth).

The term “transdermal administration” is defined as a route of administration whereby a medication is delivered through the skin of the patient for distribution throughout the patient's entire body.

The term “transmucosal administration” is defined as a route of administration whereby a medication is delivered through the mucous membrane, e.g., via inhalation, nasallly, sublingually, buccally, vaginally, rectally, or ocularly.

B. Embodiments of the Invention

According to embodiments of the present invention, there are provided pharmaceutical compositions for anesthetic purposes. The compositions comprise, consist of or consist essentially of, a combination of therapeutically effective quantities of at least one first pharmaceutically active compound and at least one second pharmaceutically active compound. In some further embodiments, the compositions optionally comprise, in addition to the above-mentioned first and second pharmaceutically active compounds, at least one third pharmaceutically active compound.

The first pharmaceutically active compound that is used in such composition comprises benzodiazepine moiety or pharmaceutically acceptable salts, hydrates, solvates or N-oxides thereof. Those having ordinary skill in the art will know that benzodiazepine moiety is a structure where a benzene ring is condensed with diazepine ring, a seven-member heterocycle with two nitrogen atoms which for the purposes of this specification may be in any positions of the ring (e.g., 1,2-diazepine, 1,3-diazepine or 1,4-diazepine). An example of a compound having benzodiazepine moiety with 1,4-diazepine structure is shown below:

One particular first pharmaceutically active compound comprising benzodiazepine moiety that can be used in pharmaceutical compositions described and claimed herein is midazolam. Other specific, non-limiting examples of first pharmaceutically active compounds comprising benzodiazepine moiety that can be used include diazepam, lorazepam, flunitrazepam, alprazolam, chlordiazepoxide, clonazepam, clobazam, bromazepam, prazepam, oxazepam and clorazepate. Each of these is also known under one or several trade names as shown in Table 1, which also discloses chemical names of such compounds. Those having ordinary skill in the art can select alternative suitable benzodiazepine-based compound for using in the compositions, if so desired.

TABLE 1 Examples of Benzodiazepine-Based Compounds That Can Be Used in Compositions Compound Chemical Name (IUPAC) Trade Name(s) Midazolam 8-chloro-6-(2-fluorophenyl)-1-methyl-4H- VERSED ®, DORMICUM ®, imidazo[1,5-a][1,4]benzodiazepine HYPNOVEL ® Diazepam 7-chloro-1-methyl-5-phenyl-3H-1,4- VALIUM ®, DIASTAT ® benzodiazepin-2-one Lorazepam 7-chloro-5-(2-chlorophenyl)-3-hydroxy- TEMESTA ®, ATIVAN ®, 1,3-dihydro-2H-1,4-benzodiazepin-2-one ORFIDAL ® Flunitrazepam 5-(2-fluorophenyl)-1-methyl-7-nitro-1H- ROHYPNOL ®, NARCOZEP ® benzo[e][1,4]diazepin-2(3H)-one and many others Alprazolam 8-chloro-1-methyl-6-phenyl-4H- XANAX ® [1,2,4]triazolo[4,3-a][1,4]benzodiazepine Chlordiazepoxide 7-chloro-2-methylamino-5-phenyl-3H-1,4- LIBRIUM ® benzodiazepine-4-oxide Clonazepam 5-(2-chlorophenyl)-7-nitro-2,3-dihydro- KLONOPIN ®, RIVOTRIL ® and 1,4-benzodiazepin-2-one many others Clorazepate 7-chloro-2,3-dihydro-2-oxo-5-phenyl- TRANXENE ® 1H-1,4-benzodiazepine-3-carboxylic acid Bromazepam 7-bromo-5-(pyridin-2-yl)-1H- LEXOTAN ®, LEXOTANIL ® benzo[e][1,4]diazepin-2(3H)-one and many others Oxazepam 7-chloro-3-hydroxy-5-phenyl-2,3-dihydro- ALEPAM ®, SERAX ® and many 1H-1,4-benzodiazepine-2-one others Clobazam 7-chloro-1-methyl-5-phenyl-1,5- URBANOL ®, FRISIUM ®, benzodiazepine-2,4(3H)-dione ONFI ® Prazepam 7-chloro-1-(cyclopropylmethyl)-5-phenyl- LYSANXIA ®, CENTRAX ® and 1,3-dihydro-2H-1,4-benzodiazepin-2-one many others

The therapeutically effective quantity of the benzodiazepine-based compound(s) in the entire pharmaceutical composition can be between about 0.01 mass % and about 5.0 mass % of the composition. In some embodiments, the therapeutic effective amount of the benzodiazepine-based compound(s) can be between about 1.0 mass % and about 3.0 mass %, for example, about 2.5 mass % of the composition.

In some applications a patient may be extra sensitive to benzodiazepines (e.g., may become excessively drowsy). For such patients, there are provided additional embodiments in which benzodiazepine(s)-containing pharmaceutical compositions described above, would additionally include a quantity of a receptor antagonist to benzodiazepines. Such a receptor antagonist would begin counteracting the effect of benzodiazepine after the surgical procedure is complete, in essence providing a slow release feature. A non-limiting example of this antagonist is flumazenil also known under trade names such as ANEXATE®, ROMAZICON® and others. The use of antagonists is also envisioned as a routine practice (i.e., not just for sensitive patients), for example, in situations when larger than typical or usual dosage of benzodiazepines is medically indicated, or recommended, or necessary. In some further applications, benzodiazepine-based compounds may be used in combination with non-benzodiazepine based sedatives such as eszopiclone, ramelteon, zolpidem, or zaleplon.

The second pharmaceutically active compound that is used in such composition is an NMDA antagonist, as this term is defined hereinabove, or pharmaceutically acceptable salts, hydrates, solvates or N-oxides thereof. One particular second pharmaceutically active compound that can be used in pharmaceutical compositions described and claimed herein is ketamine. Other specific, non-limiting examples of NMDA antagonists that can be used include dextrorphan, etomidate, methadone, memantine, amantadine and dextromethorphan. Each of these is also known under one or several trade names as shown in Table 2, which also discloses chemical names of such compounds. Those having ordinary skill in the art can select alternative suitable NMDA antagonists for using in the compositions, if so desired.

TABLE 2 Examples of NMDA Antagonists That Can Be Used in Compositions Compound Chemical Name (IUPAC) Trade Name(s) Ketamine 2-(2-chlorophenyl)-2- KETANEST ®, (methylamino)cyclohexanone KETASET ®, KETALAR ® (HCL salt) Dextrorphan 17-methyl-9a,13a,14a-morphinan-3-ol None Etomidate Ethyl-3-[(1R)-1-phenylethyl]imidazole-5- AMIDATE ®, carboxylate HYPNOMIDATE ® Methadone 6-(dimethylamino)-4,4-diphenylheptan-3-one DOLOPHINE ®, AMIDONE ® and others Memantine 3,5-dimethyladamantan-1-amine AKATINOL ®, NAMENDA ® and others Amantadine Adamantan-1-amine SYMMETREL ® Dextromethorphan (4bS,8aR,9S)-3-methoxy-11-methyl-6,7,8,8a,9,10- ROBITUSSIN ®, hexahydro-5H-9,4b-(epiminoethano)phenanthrene DELSYM ® and others

The therapeutically effective quantity of the NMDA antagonist(s) in the entire pharmaceutical composition can be between about 1.0 mass % and about 20.0 mass % of the composition. In some embodiments, the therapeutically effective amount of the NMDA antagonist(s) can be between about 4.0 mass % and about 16.0 mass %, for example, about 5.0 mass % of the composition. Accordingly, the combined quantities of both the benzodiazepine-based compound(s) and the NMDA antagonist(s), taken together, in the entire pharmaceutical composition can be between about 1.2 mass % and about 15.0 mass % of the composition, such as between about 3.0 mass % and about 12.0 mass %, for example, about 10.0 mass % of the composition.

As mentioned above, the compositions may further optionally comprise at least one third pharmaceutically active compound. In such embodiments, the third pharmaceutically active compound is a β-blocker, as this term is defined hereinabove, or pharmaceutically acceptable salts, hydrates, solvates or N-oxides thereof, or alternatively α-2-adrenergic agonist or, as another alternative, a pain reliever. In addition to, or instead of, β-blockers, the third pharmaceutically active compound may also comprise an antiemetic medicament, as this term is defined hereinabove, or pharmaceutically acceptable salts, hydrates, solvates or N-oxides thereof.

In yet another aspect, the third pharmaceutically active compound may include one or several non-steroid anti-inflammatory drug(s) (NSAID's), as this term is defined hereinabove. NSAID(s) may be so used in addition to, or instead of, β-blocker(s), and/or antiemetic(s). In a further aspect, the third pharmaceutically active compound may also comprise an antihistamine medicament, as this term is defined hereinabove, non-limiting examples of specific antihistamine medicaments that can be so used being any of hydroxyzine pamoate, hydroxyzine hydrochloride, diphenhydramine hydrochloride, meclizine, chlorpheniramine, clemastine, promethazine, or prochlorperazine, or any combination thereof. Again, antihistamine medicaments may be used in addition to, or instead of, any above-mentioned compound that may be used as the third pharmaceutically active compound.

The therapeutically effective quantity of the third pharmaceutically active compound(s) in the entire pharmaceutical composition can be between about 0.1 mass % and about 5.0 mass % of the composition. In some embodiments, the therapeutic effective amount of the third pharmaceutically active compound(s) can be between about 1.0 mass % and about 4.0 mass %, for example, about 2.5 mass % of the composition.

One particular β-blocker that can be used as the third pharmaceutically active compound in pharmaceutical compositions described and claimed herein is metoprolol. Other specific, non-limiting examples of β-blockers or α-2-adrenergic agonists or pain relievers that can be used include, propranolol, acebutolol, nadolol, atenolol, betaxolol, esmolol, bisoprolol fumarate, carvedilol, nebivolol, penbutolol, timolol, sotalol, dexmedetomidine hydrochloride, clonidine, and acetaminophen. Each of these is also known under one or several trade names as shown in Table 3, which also discloses chemical names of such compounds. Those having ordinary skill in the art can select alternative suitable β-blockers for using in the compositions, if so desired.

TABLE 3 Examples of β-Blockers That Can Be Used in Compositions Compound Chemical Name (IUPAC) Trade Name(s) Metoprolol 1-(isopropylamino)-3-[4-(2-methoxyethyl)phenoxy]propan-2-ol LOPRESSOR ®, TOPROL ® Propranolol 1-(1-methylethylamino)-3-(1-naphthyloxy)propan-2-ol CIPLA ®, INDERAL ®, and many others Acebutolol N-{3-acetyl-4-[2-hydroxy-3-(propan-2-ylamino) SECTRAL ®, propoxy]phenyl}butanamide PRENT ® Nadolol 5-{[3-(tert-butylamino)-2-hydroxypropyl]oxy}-1,2,3,4- CORGARD ® tetrahydronaphthalene-2,3-diol Atenolol 2-{4-[2-hydroxy-3-(propan-2-ylamino)propoxy] TENORMIN ® phenyl}acetamide Betaxolol 1-{4-[2-(cyclopropylmethoxy)ethyl]-phenoxy}-3- KERLONE ®, (isopropylamino)propan-2-ol BETOPTIC ®, and others Esmolol 3-{4-[2-hydroxy-3-(propan-2-ylamino)propoxy] BREVIBLOC ® phenyl}propanoate Bisoprolol 1-[4-[[2-(1-methylethoxy)ethoxy]methyl]phenoxy]-3[(1- ZEBETA ® fumarate methylethyl)amino]-2-propanol-2-butenedioate Carvedilol 3-(9H-carbazol-4-yloxy)-2-hydroxypropyl-2-(2- COREG ®, methoxyphenoxy)ethylamine CARVIL ® and many others Nebivolol 2,2′-azanediylbis(1-(6-fluorochroman-2-yl)ethanol) NEBILET ®, BYSTOLIC ® Penbutolol 1-(tert-butylamino)-3-(2-cyclopentylphenoxy)propan-2-ol LEVATOL ®, LEVATOLOL ®, and many others Timolol 1-(tert-butylamino)-3-[(4-morpholin-4-yl-1,2,5-thiadiazol-3- TIMOPTIC ®, yl)oxy]propan-2-ol BETIMOL ® and many others Sotalol N-{4-[1-hydroxy-2-(propan-2-ylamino)ethyl]phenyl} BETAPACE ® and methanesulfonamide others

One particular antiemetic that can be used as the third pharmaceutically active compound in pharmaceutical compositions described and claimed herein is ondansetron. Other specific, non-limiting examples of antiemetics that can be used include dolasetron, granisetron, palonosetron, promethazine, imenhydrinate, and meclizine. Each of these is also known under one or several trade names as shown in Table 4, which also discloses chemical names of such compounds. Those having ordinary skill in the art can select alternative suitable antiemetics for using in the compositions, if so desired.

TABLE 4 Examples of Antiemetics That Can Be Used in Compositions Compound Chemical Name (IUPAC) Trade Name(s) Ondansetron (RS)-9-methyl-3-[(2-methyl-1H-imidazol-1-yl)methyl]-2,3- ZOFRAN ®, dihydro-1H-carbazol-4(9H)-one ONDISOLV ® Dolasetron (2α,6α,8α,9aβ)-octahydro-3-oxo-2,6-methano-2H-quinolizin- ANZEMET ® 8-yl-1H-indole-3-carboxylate monomethanesulfonate, monohydrate Granisetron 1-methyl-N-((1R,3r,5S)-9-methyl-9-azabicyclo[3.3.1]nonan-3- KYTRIL ® yl)-1H-indazole-3-carboxamide Palonosetron (3aS)-2-[(3S)-1-azabicyclo[2.2.2]oct-3-yl]-2,3,3a,4,5,6- ALOXI ® hexahydro-1H-benz[de]isoquinolin-1-one Promethazine (RS)-N,N-dimethyl-1-(10H-phenothiazin-10-yl)propan-2- PHENERGAN ® amine Dimenhydrinate 2-benzhydryloxy-N,N-dimethylethanamine; 8-chloro-1,3- DRAMAMINE ®, dimethyl-7H-purine-2,6-dione GRAVOL ®, VOMEX ®, many others Meclizine (RS)-1-[(4-chlorophenyl)(phenyl)methyl]-4-(3- BONINE ®, methylbenzyl)piperazine BONAMINE ®, ANTIVERT ®, and many others

Therefore, the combined quantities of all the pharmaceutically active compounds (i.e., the benzodiazepine-based compound(s), the NMDA antagonist(s), the β-blocker(s)), and/or the antiemetic(s) taken together, in the entire pharmaceutical composition can be between about 1.3 mass % and about 20.0 mass % of the composition, such as between about 3.0 mass % and about 12.0 mass %, for example, about 10.0 mass % of the composition. Those having ordinary skill in the art will determine the most appropriate quantities of each the pharmaceutically active compound that are within the above-mentioned ranges and that are most suitable for a particular patient. As a guideline only, the following mass ratios between the pharmaceutically active compounds may be used (Table 5) for compositions where the benzodiazepine-based compound is midazolam, the NMDA antagonist is ketamine hydrochloride and the β-blocker is propanolol hydrochloride:

TABLE 5 Exemplary Mass Ratios Between Midazolam, Ketamine Hydrochloride and Propanolol Hydrochloride in the Compositions Ketamine Propanolol Ratios Midazolam Hydrochloride Hydrochloride Between about 1 2 1 and about 1 10 1 Such as between about 1 4 1 and about 1 6 1 For example 1 5 1

In one specific embodiment, which is exemplary and non-limiting, for the composition having midozalam as the first pharmaceutically active compound, ketamine as the second pharmaceutically active compound and ondansentron as the third pharmaceutically active compound, the mass midazolam:ketamine:odansentron ratio may be about 3:25:2.

The pharmaceutical compositions described herein may contain not only pharmaceutically active components but also, in some embodiments, may further comprise one or several inactive, neutral compounds which can be pharmaceutically acceptable excipient(s) or carrier(s), including, but not limited to, binder(s), antioxidant(s), adjuvant(s), synergist(s) and/or preservative(s). The mass concentration of such inactive compounds can be between about 80 mass % and about 99 mass % of the entire pharmaceutical composition, such as between about 85 mass % and about 95 mass %, e.g., about 90 mass %.

Some embodiments of the invention are directed to pharmaceutical formulations that are formulated as suitable for rectal administration, nasal administration (including via a nasal spray), oral spray administration, transdermal administration, and transmucosal administration including that utilizing a trnasmucosal gel. In certain embodiments, these compositions may optionally comprise binder(s) and/or excipient(s). They can be prepared by first mixing the pharmaceutically active compounds described above with suitable binder(s) and/or excipient(s) followed by molding or compressing, if applicable.

Typical binder(s) that can be used for fabricating the formulations mentioned above include, without limitation, polyglycols as defined above, such as, e.g., polyethylene glycols (PEGs), polyethylene oxides (POE), methoxypolyethylene glycols, polypropylene glycols, polybutylene glycols or derivatives thereof having a molecular weight that is sufficient to provide the necessary hardness and time for dissolution of the troche; for example, the acceptable molecular weight can be within the range of between about 1,000 Daltons and about 8,000 Daltons. In some embodiments PEG-1450 or PEG-400 can be used. Non-limiting examples of some specific polyglycol derivatives that can be used are:

(a) PEG-laureates and dilaureates (e.g., PEG-10-, PEG-12-, PEG-20-, PEG-32-laurates, PEG-20- and PEG-32-dilaurates, PEG-20-glyceryl-, PEG-30-glyceryl- and PEG-40-glyceryl-laurates, PEG-80-sorbitan laurate);

(b) PEG-oleates, dioleates and trioleates (e.g., PEG-12-, PEG-15-, PEG-20-, PEG-32, PEG-200- and PEG-400-oleates, PEG-20- and PEG-32-dioleates, PEG-20-trioleate, PEG-25-glyceryl trioleate, PEG-20-glyceryl- and PEG-30-glyceryl-oleates, PEG-40-sorbitan oleate);

(c) PEG-stearates and distearates (e.g., PEG-15-, PEG-40-, PEG-100-stearates, PEG-32-distearate and PEG-20-glyceryl stearate)

(d) castor, palm kernel, corn and soya oil derivatives of PEG (e.g., PEG-35-, PEG-40- and PEG-60-castor oils, PEG-40-, PEG-50- and PEG-60-hydrogenated castor oils, PEG-40-palm kernel oil, PEG-60-corn oil, PEG-30-soya sterol);

(e) other PEG derivatives (e.g., PEG-24- and PEG-30-cholesterol, PEG-25-phytosterol, PEG-6- and PEG-8-caprate/caprylate glycerides, tocopheryl PEG-100 succinate, PEG-15-100 octylphenol products and PEG-10-100 nonylphenol products);

(f) other products such as polyglyceryl-10-laurate, POE-9- and POE-23-lauryl ethers, POE-10- and POE-20-oleyl ethers, POE-20-stearyl ether, polysorbates-20 and 80, polyglyceryl-10-oleate, Tween 40, Tween 60, sucrose monostearate, monolaurate and monopalmitate and various products of Poloxamer series.

Typical excipient(s) that can be used for fabricating the compositions mentioned above include, without limitation, gelatin, sodium saccharin, stevioside, peppermint oil, cherry flavor, lemon oil, raspberry flavor, or any natural or artificial fruit, vegetable, flower, beverage or candy flavor.

As stated above, the compositions may optionally further comprise one or several antioxidant(s). If antioxidant(s) are used, non-limiting examples of those that can be used include α-tocopherol acetate, acetone sodium bisulfite, acetylcysteine, ascorbic acid, ascorbyl palmitate, butylated hydroxyanisole, butylated hydroxytoluene, cysteine, cysteine hydrochloride, tocopherol natural, tocopherol synthetic, dithiothreitol, monothioglycerol, nordihydroguaiaretic acid, propyl gallate, sodium bisulfite, sodium formaldehyde sulfoxylate, sodium metabisulfite, sodium sulfite, sodium thiosulfate, thiourea and tocopherols.

As stated above, the compositions may optionally further comprise one or several adjuvant(s) or synergists(s). If adjuvant(s) or synergists(s) are used, non-limiting examples of those that can be used include citric acid, EDTA (ethylenediaminetetraacetate) and salts, hydroxyquinoline sulfate, phosphoric acid and tartaric acid.

As stated above, the compositions may optionally further comprise one or several preservative(s). If preservative(s) are used, non-limiting examples of those that can be used include benzalkonium chloride, benzethonium chloride, benzoic acid and salts, benzyl alcohol, boric acid and salts, cetylpyridinium chloride, cetyltrimethyl ammonium bromide, chlorobutanol, chlorocresol, chorhexidine gluconate or chlorhexidine acetate, cresol, ethanol, imidazolidinyl urea, metacresol, methylparaben, nitromersol, o-phenyl phenol, parabens, phenol, phenylmercuric acetate/nitrate, propylparaben, sodium benzoate, sorbic acids and salts, β-phenylethyl alcohol and thimerosal.

The pharmaceutical formulation can be administered to a subject in need of conscious sedation, procedural sedation, analgesia and/or pre-sedation, and in general to any kind of non-general anesthesia, by various local administrations. More specifically, the pharmaceutical formulations described herein may be prescribed by ordinarily skilled medical practitioners such as physicians, as the means of conscious sedation or pre-sedation. This is intended to be used by certain patients who experience or expect to experience high anxiety, bouts of panic attacks, disquietude, apprehension, angst or similar feeling of psychological discomfort or distress prior to, or during, some medical or surgical procedures described in more detail below. The patients may be of any age, i.e., including children, adolescents and adults.

For example, the formulation can be used prior to various outpatient surgeries and medical procedures, both invasive and non-invasive, such as an ophthalmic surgery, outpatient medical or surgical procedures, dental procedures, of urological procedures, obstetric and gynecological procedures, gastrointestinal procedures, otolaryngological procedures, cosmetic surgery procedures, dermatological procedures, podiatric procedures, orthopedic procedures, emergency medical treatments, psychiatric treatments, and veterinarian procedures.

Specific representative examples of the procedures that are amenable to the use of the formulation include, without limitation, cataract surgery, glaucoma surgery, corneal surgery, eyelid surgery, retinal surgery, tooth extraction, oral surgery, root canal surgery, medical imaging procedures (e.g., MRI or CAT scanning, especially for patients suffering from claustropbobia), biopsy, bone marrow harvesting, colonoscopy, endoscopy and laparoscopy.

In some non-limiting embodiments, various routes of local administration may be used. Non-limiting examples of acceptable local routes include rectal administration, nasal administration (including via a nasal spray), oral spray administration, transdermal administration, and transmucosal administration including that utilizing a transmucosal gel. Those having ordinary skill in the art will prepare compositions that are suitable for a particular route of local administration that is selected. The local administration may be used instead or intravenous administration or to complement the latter, as appropriate.

It will be understood by those having ordinary skill in the art that the specific dose level and frequency of dosage for any particular patient may be varied and will depend upon many factors including the activity of the specific compound employed, the metabolic stability and length of action of that compound, the age, body weight, general health, gender, diet and the severity of the particular condition being treated.

According to further embodiments, methods for fabricating the above-described pharmaceutical compositions are provided. A one-batch formulation method may be used, where the components of the pharmaceutical formulation can be combined in single container; the components may be added to the container simultaneously or consecutively. Alternatively, a two- or multiple-batch method(s) may be used if desired, where each component of the pharmaceutical formulation can be combined in separate container followed by combining the contents of each container.

In one exemplary, non-limiting procedure, pre-measured quantities of each ingredient in the form of dry powder can be mixed to form a dry blend followed by mixing it with a liquid or gel base as described above.

In additional embodiments, pharmaceutical kits are provided. The kit includes a sealed container approved for the storage of solid pharmaceutical compositions, the container containing one of the above-described pharmaceutical compositions an instruction for the use of the composition and the information about the composition are to be affixed to the container or otherwise enclosed with it.

The following examples are provided to further elucidate the advantages and features of the present invention, but are not intended to limit the scope of the invention. The examples are for the illustrative purposes only. USP pharmaceutical grade products were used in preparing the formulations described below.

Example 1. Preparing a Pharmaceutical Composition in the Form of a Troche

A pharmaceutical composition may be prepared as described below. The following products can be used in the amounts and concentrations specified:

-   -   (a) about 0.2 g of midazolam;     -   (b) about 2.0 g of ketamine hydrochloride;     -   (c) about 0.2 g of propanolol ondansetron hydrochloride;     -   (d) about 1 mL of lemon oil flavoring; and     -   (e) about 15.5 g of standard troche base (comprising polyglycol         1450, polyglycol 400, gelatin, sodium saccharin and steviaside).

The troche base can be melted at low heat while being stirred; when completely molten, the heat can be turned off with continued stirring. All the dry ingredients, pre-weighed can be added into the molten base followed by adding the flavoring and well mixed together.

A half-moon shaped troche mold can be lightly sprayed with Pam (or a suitable oil/releasing agent) to cover the entire surface of the mold and the mixture prepared as explained above can then be poured into the mold and allowed to cool and harden at room temperature. A heat gun can then be used to smooth out the surface followed by another round of cooling at room temperature followed by removing the so prepared troche from the mold, placing it into a prescription vial and labeling the vial. The troche is now ready to be administered.

Example 2. Preparing a Pharmaceutical Composition in the Form of a Suppository

A pharmaceutical composition may be prepared as described below. The following products can be used in the amounts and concentrations specified:

-   -   (a) about 0.3 g of midazolam;     -   (b) about 2.5 g of ketamine hydrochloride;     -   (c) about 0.249 g ondansetron hydrochloride dihydrate;     -   (d) about 2.0 g of silica gel; and     -   (e) about 235 g of standard suppository base, i.e., waxy         fatty-acid base comprising a blend of saturated polyglycolysed         glycerides.

The suppository base can me melted in a beaker at a temperature of about 50° C. The rest of ingredients (i.e., midazolam, ketamine HCl, ondansetron hydrochloride dihydrate, and silica gel), pre-weighed, can be added into the molten suppository base while being constantly stirred, followed by discontinuing the heat with continued mixing until a homogeneous suspension is obtained. Finally, using a syringe with rectal tip the warm suspension can be placed into 2.4 g suppository shells and allowed to cool, followed by heat sealing the suppository shells, labeling and packaging.

Example 3. Preparing a Pharmaceutical Composition in the Form of a Nasal Spray

A pharmaceutical composition may be prepared as described below. The following products can be used in the amounts and concentrations specified:

-   -   (a) about 2.5 g of midazolam;     -   (b) about 10.5 g of ketamine hydrochloride;     -   (c) about 1.245 g ondansetron hydrochloride dihydrate;     -   (d) about 0.1 g of edetate disodium powder;     -   (e) about 1.0 g of 1% solution of benzalkonium chloride; and     -   (f) about 100.0 mL of purified water.

Midazolam, ketamine hydrochloride, and ondansetron hydrochloride dihydrate, pre-weighed, can be combined in an appropriate container and about 70% of water can be added while being constantly stirred, followed by adding a quantity of hydrochloric acid sufficient to have midazolam and ondansetron completely dissolve. The solution of benzalkonium chloride and edetate disodium powder can be then added and mixed in to dissolve. The pH of the resulting solution can then be adjusted to be within about 2.8 to 3.2 range using a solution of hydrochloric acid and/or sodium hydroxide followed by packaging with metered nasal spray tip.

Example 4. Preparing a Pharmaceutical Composition for Transdermal Administration

A pharmaceutical composition may be prepared as described below. The following products can be used in the amounts and concentrations specified:

-   -   (a) about 0.3 g of midazolam;     -   (b) about 2.5 g of ketamine hydrochloride;     -   (c) about 0.240 g ondansetron hydrochloride dihydrate;     -   (d) about 22.0 g of lecithin organogel liquid (available from,         e.g., Letco Medical, Decatur, Ala.); and     -   (e) about 100.0 g of 30% PLURONIC F-127® gel.

Midazolam, ketamine hydrochloride, and ondansetron hydrochloride dihydrate, pre-weighed, can be combined in an empty tared mixing jar followed by adding lecithin organogel and PLURONIC F-127 mixing using an automatic mixer on speed 2 and filling a tube with the product and sealing it.

Example 5. Preparing a Pharmaceutical Composition for Transmucosal Administration in the Form of a Mucoadhesive Gel

A pharmaceutical composition may be prepared as described below. The following products can be used in the amounts and concentrations specified:

-   -   (a) about 0.3 g of midazolam;     -   (b) about 2.5 g of ketamine hydrochloride;     -   (c) about 0.249 g ondansetron hydrochloride dihydrate;     -   (d) about 15.0 g of PLURONIC F-127®;     -   (e) about 4.0 g of sodium hyaluronate, cosmetic grade;     -   (f) about 3.0 g of CARBOMER 940® powder; and     -   (g) about 100.0 mL of purified water.

Midazolam, ketamine hydrochloride, and ondansetron hydrochloride dihydrate, pre-weighed, can be combined in an appropriate container and about 50% of water can be added while being constantly stirred, followed by adding pre-weighed quantities of sodium hyaluronate and PLURONIC F-127®, with continued mixing. Then a pre-weighed quantity of CARBOMER 940® powder may be added, taking care that clumping would not occur, and the use of high shear mixing may be needed to achieve complete hydration of the gel. Then, mixing may continue until a clear gel is obtained followed by adding the remainder of water, packaging and labeling.

Although the invention has been described with reference to the above examples, it will be understood that modifications and variations are encompassed within the spirit and scope of the invention. Accordingly, the invention is limited only by the following claims. 

What is claimed is:
 1. A method for carrying out an invasive or a non-invasive medical procedure, comprising administering to a patient in need of conscious sedation, procedural sedation, analgesia, pre-sedation or a non-general anesthesia a pharmaceutical composition as the first step of the procedure, the pharmaceutical composition comprising: (a) a therapeutically effective quantity of a first pharmaceutically active compound selected from the group consisting of midazolam, diazepam, lorazepam, flunitrazepam, alprazolam, chlordiazepoxide, clonazepam and clorazepate, and pharmaceutically acceptable salts, hydrates, solvates or N-oxides thereof; (b) a therapeutically effective quantity of a second pharmaceutically active compound selected from the group consisting of ketamine, dextrorphan, etomidate, methadone, memantine, amantadine, dextromethorphan, and pharmaceutically acceptable salts, hydrates, solvates or N-oxides thereof; (c) optionally, a pharmaceutically suitable binder therefor; and (d) optionally, a pharmaceutically acceptable excipient, wherein the pharmaceutical composition is administered by a method selected from the group consisting of rectal administration, nasal spray administration, oral spray administration, transdermal administration, and transmucosal administration, to carry out the medical procedure thereby.
 2. The method of claim 1, wherein the pharmaceutical composition further comprises a therapeutically effective quantity of a third pharmaceutically active compound selected from the group consisting of β-blockers, antiemetic medicaments, NSAIDs, antihistamines, α-2-adrenergic agonists, and pain relievers and combinations thereof, or pharmaceutically acceptable salts, hydrates, solvates or N-oxides thereof.
 3. The method of claim 2, wherein the β-blocker, the α-2-adrenergic agonist or the pain reliever is selected from the group consisting of metoprolol, propranolol, acebutolol, nadolol, atenolol, betaxolol, esmolol, bisoprolol fumarate, carvedilol, nebivolol, penbutolol, timolol, sotalol, dexmedetomidine hydrochloride, and acetaminophen.
 4. The method of claim 2, wherein the antiemetic medicament is selected from the group consisting of ondansentron, dolasetron, granisetron, palonosetron, promethazine, imenhydrinate, and meclizine.
 5. The method of claim 2, wherein the NSAID is selected from the group consisting of bromfenac, ketorolac, etodolac, sulindac, diclofenac, aceclofenac, nepafenac, tolmetin, indomethacin, nabumetone, ketoprofen, dexketoprofen, ibuprofen, flurbiprofen, dexibuprofen, fenoprofen, loxoprofen, oxaprozin, naproxen, aspirin, salicylic acid, diflunisal, salsalate, mefenamic acid, meclofenamic acid, flufenamic acid, tolfenamic acid, meloxicam, piroxicam, ternoxicam, droxicam, lornoxicam, isoxicam, celecoxib, rofecoxib, valdecoxib, parecoxib, lumiracoxib, etoricoxib, firocoxib, nimesulide, clonixin, and licofelone.
 6. The method of claim 2, wherein the antihistamine is selected from the group consisting of hydroxyzine pamoate, hydroxyzine hydrochloride, diphenhydramine hydrochloride, meclizine, chlorpheniramine, clemastine, promethazine, and prochlorperazine.
 7. The method of claim 2, wherein the pharmaceutical composition further comprises a therapeutically effective quantity of a receptor antagonist to benzodiazepines.
 8. The method of claim 7, wherein the receptor antagonist is flumazenil.
 9. The method of claim 2, wherein the first pharmaceutically active compound is medazolam, the second pharmaceutically active compound is ketamine and the third pharmaceutically active compound is metoprolol, at a medazolam:ketamine:metoprolol ratio of between about 1:2:1 and about 1:10:1 by mass.
 10. The pharmaceutical composition of claim 2, wherein the first pharmaceutically active compound is medazolam, the second pharmaceutically active compound is ketamine and the third pharmaceutically active compound is ondansentron, at a medazolam:ketamine:ondansentron ratio of about 3:25:2 by mass.
 11. The method of claim 1, wherein the binder is present and comprises a polyglycol selected from the group consisting of polyethylene glycol, polyethylene oxide, methoxypolyethylene glycol, polypropylene glycol and polybutylene glycol, or derivatives thereof, having a molecular weight that is sufficient to provide suitable hardness and time for dissolution of the troche.
 12. The method of claim 1, wherein the excipient is present and comprises a member selected from the group consisting of gelatin, sodium saccharin, stevioside, peppermint oil, cherry flavor, lemon oil, raspberry flavor, any natural or artificial fruit, vegetable, flower, beverage or candy flavor, and combinations thereof.
 13. The method of claim 1, wherein the binder comprises a product selected from the group consisting of methoxypolyethylene glycol, polypropylene glycol, polybutylene glycol, PEG-laureates, PEG-dilaureates, PEG-oleates, PEG-dioleates, PEG-trioleates, PEG-stearates, PEG-distearates, castor oil derivatives of PEG, palm kernel oil derivatives of PEG, corn oil derivatives of PEG, soya oil derivatives of PEG, cholesterol derivatives of PEG, phytosterol derivatives of PEG, caprate/caprylate glycerides derivatives of PEG, tocopheryl succinate derivatives of PEG, octylpheno derivatives of PEG, nonylphenol derivatives of PEG, polyglyceryl-10-laurate, polyglyceryl-10-oleate, POE-lauryl ethers, POE-oleyl ethers, POE-stearyl ethers, polysorbates, onostearate, monolaurate and monopalmitate derivatives of sucrose, and products of poly(oxypropylene)-co-poly(propylene oxide) family.
 14. The method of claim 1, wherein the medical procedure is selected from the group consisting of an ophthalmic surgery, a dental procedure, an outpatient medical procedure, obstetric and gynecological procedures, a gastrointestinal procedure, an otolaryngological procedure, a cosmetic surgery procedure, a dermatological procedure, a podiatric procedure, an orthopedic procedure, an emergency medical treatment, a psychiatric treatment, a urological procedure, and a veterinarian procedure,
 15. The method of claim 14, wherein the ophthalmic surgery is selected from the group consisting of a cataract surgery, a glaucoma surgery, corneal surgery, eyelid surgery, and retinal surgery.
 16. The method of claim 14, wherein the dental procedure is selected from the group consisting of a tooth extraction, an oral surgery, and a root canal surgery.
 17. The method of claim 14, wherein the outpatient surgical procedure is selected from the group consisting of a medical imaging procedure, biopsy, bone marrow harvesting, colonoscopy, endoscopy, and a laparoscopic procedure.
 18. The method of claim 14, wherein the pharmaceutical composition is administered to induce conscious sedation or pre-sedation in a patient in need thereof.
 19. The method of claim 18, wherein the patient experiences or expects to experience high anxiety, bouts of panic attacks, disquietude, apprehension, or angst prior to, or during, the medical procedure
 20. The method of claim 1, wherein the binder is present and the pharmaceutical composition is administered by rectal administration. 